High manifestations of food insecurity and hunger among pregnant and lactating women during post-conflict in Tigray, Ethiopia: a community-based study

Background Food insecurity is a state or condition in which people have limited or uncertain physical, social, and economic access to safe, sufficient, and nutritious food to meet their dietary needs. Since no thorough evaluation was carried out to determine the degree of household food insecurity in Tigrayan communities in the aftermath of the conflict. This study aims to describe household-level food insecurity status among pregnant and lactating women during the post-armed conflict in Tigray, Ethiopia. Method Descriptive research was designed to assess household food insecurity. A multi-stage sampling technique was used for this study. One thousand two hundred forty-nine households were selected systematically following a list of food insecure households. Descriptive statistical values, including frequency counts, percentages, minimum values, maximum values, and averages, were calculated to quantify the indicators under study. Household food insecurity and hunger Scale measurement using the standardized Food and Agriculture Organization standard. Results The mean age (± SD) of the mothers was 28.35 ± 5.91 years. More than three fourth of the participants 1010(80.93%) were rural residents. The survey result showed that 88.8% of the pregnant and lactating were food insecure. Half (50.1%) of the households were hungry,one month before the study, 78.5% of the families expressed concern about running out of food and 6.4% had severe hunger. Conclusions The food insecurity levels and hunger prestige of the study communities were excessively high. This is in the context of a region affected by intense armed conflict. It is commended that the study communities need to be safeguarded from the direct and long-term consequences of armed conflict-caused household food insecurity. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-024-06550-8.


Introduction
A state or situation known as "food insecurity" occurs when a person's physical, social, or economic access to sufficient, appropriate, and safe food to match their dietary needs or preferences for a productive, healthy, and active life is restricted or unclear [1].Hunger and its up-to-date data to plan, allocate resources, and target recipients.But when the peace agreement was signed, no thorough evaluation was carried out.To determine the degree of household food insecurity in Tigrayan communities in the aftermath of the conflict, the current study was designed.

Methodology
Study setting: This study was carried out in Tigray regional state, Ethiopia.The survey was conducted from June 24, 2023, to July 25, 2023, Study design: A community-based cross-sectional study using a quantitative research approach.The study population was all pregnant or lactating women in the Tigray region.The study unit was every home with a pregnant or lactating woman in the selected Tabias or Kebelles.

Sampling frame
Health extension workers (HEWs) and partners operating in the selected districts provided the list of lactating and pregnant women from the health posts (HP) of the selected tibias and kebeles of the woreda, which served as the sampling frame for the households.

Sample size determination
The sample was selected from randomly selected districts to participate in the study.The sample size was calculated using the single population proportion formula assuming a 55% (1) proportion of acute malnutrition among PLW, 5% margin of error, 10% non-response rate, 95% confidence interval, and 3 design effects.

Sampling technique and procedure
A multi-stage sampling technique was used for this study.From the seven zones of the region, two zones (Central and South Eastern zones) were chosen using a straightforward random selection method (lottery system).A basic random selection technique was used to choose two districts (Hintallo and Samre) and five (Abi-Adi, Kolla Temben, Rural Adwa, Tahtay Maychew, and Adet) accompanying disorders claim nine million lives annually worldwide, mostly in developing countries [2].
There is a close connection between violent conflict and food insecurity [3].Food insecurity is a common consequence of conflict, and food insecurity and related social tensions are linked to a higher risk of conflict outbreaks [4].Put differently, not only does food insecurity result from war, but food insecurity and malnutrition can also serve as catalysts for conflict and serve as conduits for other complaints in situations where there has been a conflict [4,5].
Relapses into violence are 40% more common in postwar nations with high levels of food insecurity than in those with low levels, according to dependable data from the World Food and Agriculture Organization (FAO) [6].In general, food shortages and violence impede development efforts by causing physical infrastructure damage, upsetting markets and trade, and taking financial and human resources away from productive industries [7].
From Tigray's perspective, there were several ways in which the recent armed conflict and the tight siege that accompanied it threatened regional food security.In addition to claiming the lives of useful civilians, the battle severely damaged agricultural inputs and infrastructure, including seeds, fertilizer, pesticides, herbicides, and other chemicals [8].In general, the inhabitants of Tigray have experienced intense conflicts that have impeded the security of food and nutrition as well as the economic development of the region [9].89% of households experienced food insecurity at the end of 2022, with 47% experiencing a food crisis or worse, according to the WFP's most recent proxy poll [10].
Nevertheless, food security and nutrition conditions in the region have not improved, if anything they have gotten worse, nine months after the Pretoria peace treaty was signed.Humanitarian help has taken longer to resume.The rising demand has not been met by the available supply.A tiny percentage of persons in need were receiving emergency humanitarian relief, according to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA).
Moreover, there were continuous difficulties in distributing the food assistance once it got to the area.Currently, there is a complete shutdown of the supply and distribution of even more terrible food due to claims of significant diversion of humanitarian goods.Furthermore, the unpaid status of tens of thousands of federal personnel and pensioners has caused them to continue to live in difficulty.
When combined, the aforementioned and other relevant factors are anticipated to worsen the food and nutrition crises in the region.Pregnancy and lactation households' food insecurity levels require accurate and districts from the South Eastern and Central zones, respectively.Before data collection, a minimum of 20% of Tobias were chosen from each district using a basic random selection technique.From each cluster/Tabia, at least 30 PLW with a minimum of one kid between the ages of 6 and 59 months were included.For sampling, a list of homes containing a pregnant and nursing mother was acquired from the field office of the relevant partner or health extension workers (Table 1).

Data collection tools and procedure
A standardized tool was used to collect the data.The questions were arranged into socio-demographic, obstetric, Food insecurity characteristics, and others.A standardized paper questionnaire was used to collect data from research participants.After extensive revision, the final version of the English questionnaire will be developed.An individual who has fluency in both English and Tigrigna languages will translate the English version to Tigrigna and another individual of similar ability will then back translate the agreed Tigrigna version of the questionnaire to English to check for any inconsistencies or distortion in the meaning of words.Also, it was pretested in 5% of the study population.The data was gathered using an electronic data collecting tool (ODK).

Data collection
Quantitative information was collected from PLW at selected HHs in two zones and seven districts using a standardized questionnaire.Participants in the study were interviewed at a preselected home.One of the components of the structured quantitative questionnaire was the socio-demographic parameters and demographic traits, along with household food security.

Food insecurity measurement
Every question had a four-week (30-day) memory period.First was the incidence question, which asked the respondent if the condition had happened at all during the preceding four weeks.When a respondent answered "yes" to the occurrence question, the next question was asked to find out how often the condition had occurred over the preceding four weeks: seldom (one or twice), sporadically (three to ten times), or frequently (more than ten times).The numbers 0 and 1, respectively, were assigned to the "no" and "yes" responses.The totals for the three categories-rarely, occasionally, and frequently-were 1, 2, and 3, respectively.Consequently, the frequency of occurrence score of a particular family on the nine HFIAS questions may vary.

Household food insecurity experience scale (HFIES) Measures
There are eight questions on the household food insecurity experience scale; one is not included in the HFIAS.There are no questions regarding the frequency of occurrence.The score for the HFIES ranges from 0 to 8.While the household with the higher score has significant levels of food insecurity, the lower-scoring home has little to no food insecurity.Families that scored zero had no food insecurity, three to seven indicated mild food insecurity, six to seven indicated moderate food insecurity, and seven to eight indicated extreme food insecurity (hunger) [5,6].

Household Hunger Scale (HHS) measures
The Household Hunger Scale consists of the final three questions (Q7, Q8, and Q9) out of the nine HFIAS questions.The frequency-of-occurrence questions were used to assess the amount of hunger in the questioned AverageHFIASScore = Sum of HFIAS scores in thesample Number of HFIAS scores(i.eHouseholds)inthesamplehouseholds.HHS has a total score range of 0 to 6.Using scores of 0-1, 2-3, and 4-6, respectively, households were classified as having little or no hunger, moderate hunger, or severe hunger [5].

Data quality assurance
Achieving and sustaining data quality involved aspects such as supervision, training, and the gathering of pilot data before real data collocation.

Data analysis
Every day, supervisors verified that the data were complete.Data encoders then input the data into SPSS, and the research team used SPSS software version 24 to clean and analyze the data.To quantify the indicators, descriptive statistical values were computed and then evaluated and displayed using tables and bar graphs.These values included frequency counts, percentages, minimum values, maximum values, and averages.

Socio-demographiccharacteristics of mothers (1249)
The study comprised 1249 community-dwelling breastfeeding and pregnant women (response rate: 99.5%).The women's mean age (± SD) was 28.35 ± 5.91 years.There were 4.46 households on average.Eighty-nine percent (80.93%) of the participants in the study lived in rural areas.Out of all the women examined, 288 (23.08%) had an educational status and were unable to read and write, and more than half of them, 662 (53.04%), were farmers by occupation (Table 2).

II Four types of indicators can be calculated
1. Household food insecurity access-related conditions 2. Household food insecurity access-related domains 3. Household food insecurity access scale score 4. Household food insecurity experience scale 5. Household hunger scale 6. Household food insecurity access prevalence

Household food insecurity access-related conditions
One month before the study, over three-quarters (78.5%) of the families expressed concern about running out of food.In a similar vein, over two-thirds of the households did not have enough money to eat the foods they desired.A limited variety of foods and some items that they did not want to eat are required to be eaten by more than three-fourths (78.8%) and approximately one-third (34.6%) of households, respectively.
In more than half of the families (57.6%), there is never any food of any type available.In the four weeks before the study, at least some members of more than half (52.4%) of the families experiencednighttime hunger.At least some members of the household fast for the entire day and night in around one-third (30.3%) of the homes (Table 4).

Household food insecurity access-related domains
Food insecurity (access) can be divided into three categories: inadequate quality (including food variety and preferences), anxiety and uncertainty about the household food supply (Question 1), and insufficient food intake and its physical effects (Questions 5-9).Concerns about the availability of food in the home are present in more than three-quarters of the households.Similarly, in the month preceding the study, three out of five households (60.6%) reported inadequate food quality, including preferences for food types and diversity.Inadequate food intake and associated physical effects have affected about 58.0% of the households (Table 4).

Household food insecurity experience scale
According to the household food insecurity experience scale, about one in ten households (11.2%) do not have any experience with food insecurity; this percentage was marginally higher in the south-eastern zone (13.8%) than in the central zone (10.1%).In the southeastern zone, the percentage of households experiencing mild to moderate food insecurity was approximately 14.6%, whereas in the central zone, it was substantially higher at 31.9%.Severe household food insecurity has affected over two out of every five households (42.3%), with nearly half (48.7%) in the central zone and more than one-fourth (27.0%) in the southeastern zone (Table 4).

Household Hunger Scale (HHS)
Only half (49.9%) of the households have little or no hunger.More than two in five (43.7%) and 6.4% of households  have moderate and severe hunger, respectively.Around one-third (30.3%) and half (49.4%) in southeastern and central zones, respectively have moderate hunger.Severe hunger was slightly higher in the central zone (6.8%) compared to the southeastern zone (5.4%) (Table 4).

Household food insecurity access prevalence
In Tigray, just about one in ten homes (11.9%) had enough food, with the percentage significantly higher in the southeastern region (15.4%)than in the central zone (10.5%).3.8% and 17.5% of households, respectively, experienced mild to moderate food insecurity.
One month before the survey, nearly two-thirds (66.9%) of the households experienced acute food insecurity; this percentage was substantially greater in the central zone (71.9%) than in the southeastern zone (54.9%) in Tigray (p < 0.001).One month before the survey, approximately 90% of families (88.1%) experienced food insecurity.This was notably greater in the central zone of Tigray (89.5%) than in the southeastern zone (84.6%) (p = 0.014) (Table 4).

Discussion
Food security and stability are closely related [10].On the other hand, particularly in the globalized era, armed conflicts can be a significant contributor to food insecurity that affects areas outside of the front lines of war; the recent food crises have highlighted the structural difficulties in preventing food insecurity in conflict environments [11].
In Tigray, Northern Ethiopia, the degree of food insecurity (access and experience) and the state of hunger among households affected by the post-armed conflict are examined.According to the HFIAS scale, this survey indicates that, respectively, 11.2% and 88.8% of the households were food secure and food insecure.According to the HFIES measure, 88.9% of the households experienced food insecurity, while 11.1% of the households reported being food secures.
The findings showed a high prevalence of food insecurity among the households under study, which is consistent with the World Food Program's (WFP) assessment, which found that 89% of households in the IPC report (2010) and 88% of households in a study conducted in Pakdasht, Iran [12], were food insecure, along with other severe food security outcomes of armed conflict [13,14].
According to the HHS scale, 64.1% of the families had little to no hunger and more than one in three (35.8%) of the households experienced moderate to severe hunger.It was comparable to the FAO report.In Ukraine, acute hunger currently affects 26% of the population [15].
Forty-three percent of these households had extreme food insecurity, and thirty percent of them had at least one member who had gone hungry for the entire day or moved out to sleep in the six months before the interview owing to a lack of food or insufficient funds to buy food.
Due to the armed war, households' economic activities and production were disrupted, which resulted in a high prevalence of food insecurity and related problems.The armed conflict in the study communities may have made household food insecurity worse, as reported by the Bureau of Agriculture and Rural Development of Tigray, which reports that 75% of the livestock were killed or looted, all poultry out-growers were disrupted, 85% of all milk processes were disturbed, and 65% of forage processors became dysfunctional [16].
This study highlights a significant issue with the amount, variety, and/or quantity of food that is unavailable for consumption.Due to a lack of resources, household members have noticed a decline in the variety and quality of their food as well as a decrease in the number of meals they eat.The majority of the households expressed concern that they might not have enough food and wouldn't be able to enjoy their favorite cuisines.
In addition, households were required to eat fewer food types, smaller meals, and stuff they did not want to eat.The severity of the armed conflict led to household food insecurity, as evidenced by the fact that over one-third of the homes went without food for the entire day and night.
The continuous armed conflict was the primary source of the concerning food crisis scenario, especially in homes where livelihoods had been lost.One of the reasons for the high levels of food insecurity may be a lack of physical or financial access to enough food as a result of the armed conflict, the siege, or the interruption of humanitarian aid.Long-term, intense combat drove up food prices, which in turn caused poverty, economic damage, and displacement from the battle, and unmanageably high local food prices.
Food security levels have decreased before the war (88.8%), during the war (85.1%), and prewar (43.2%) notwithstanding the cease-fire that was negotiated in Tigray, Ethiopia, and during the postwar scenario.To improve food access and the brittleness of the food systems in the study communities in Tigray, Northern Ethiopia, unrestricted humanitarian access, income-generating activities, and local price controls can therefore be discussed as short-term majors.During the war, the people used little of the reserved food items, but during the post-war period, the reserved food was exhausted and no food aid was provided to the people.

Conclusions
The food insecurity and hunger status among pregnant and lactating women in the study community were wide excessively high.The armed conflict has a significant negative effect on food security in the Tigray regional state besides, the socio-economic deprivation.It can lead to long-term negative health implications and chronic malnutrition.It is commendable that the study populations should be protected against the short-and long-term effects of family food poverty brought on by armed conflict and socio-economic deprivation.Governments and non-governmental organizations should give special attention, support, and interventions to improving smallholder farmers that increase food self-sufficiency.Additionally, enhancement in investment in agricultural research; improvement in markets, infrastructures, and institutions; and good macroeconomic policies and political systems.

Table 1
Sample distribution for the survey, 2023

Table 2
Socio demographic characteristics lactating and pregnant mothers

Table 3
Obstatric characterstics pregnant and lactating mothers

Table 5
Household food insecurity experience scale and Hunger scale stratified by pre-war and war period, Tigray region, 2023 (n = 1249)